Version 3
Name of responsible (ratifying) committee Health & Safety Committee
24.09.14. Date ratified
Document Manager (job title)
Date issued
Review date
Electronic location
Related Procedural Documents
Key Words (to aid with searching)
Consultant Occupational Health Physician
07 th October 2014
06 th October 2017
Health and Safety policies
Trust policies: Hepatitis B- protecting employees & patients; Control of TB in NHS employees; Immunisation of Healthcare and
Laboratory Staff
Measles; Mumps; Rubella; Varicella;
Vaccination; MMR vaccine; Occupational health and safety.
Version Tracking
Version Date Ratified
3 24.09.14.
Brief Summary of Changes
No material change. Previous version review date
Author
Dr S Harvey
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expired.
CONTENTS
Quick Reference Guide ……………………………………………………………page 3
Introduction ………………………………………………………………………….page 4
Purpose ………………………………………………………………………………page 4
Scope …………………………………………………………………………………page 4
Definitions ……………………………………………………………………………page 4-6
Duties and responsibilities ………………………………………………………….page 6
Process ………………………………………………………………………………page 7,8
Training requirements ……………………………………………………………….page 8
References and Associated Documentation ……………………………………..page 8
Equality and Diversity Statement ………………………………………………….page 8,9
Monitoring Compliance with and the effectiveness of procedural documents. Page 10
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This policy must be followed in full when developing or reviewing and amending Trust procedural documents.
For quick reference the guide below is a summary of actions required. This does not negate the need for the document author and others involved in the process to be aware of and follow the detail of this policy. The quick reference can take the form of a list or a flow chart, if the latter would more easily explain the key issues within the body of the document
1. Under the Health and Safety at Work Act 1974 employers and employees have specific duties to protect, as far as reasonably practicable, those at work and others who may be affected by their work activity, e.g. patients.
2. The control of Substances Hazardous to Heath (COSHH) Regulations 2002 require employers to assess the risks from exposure to hazardous substances, including pathogens (called biological agents in COSHH) and to bring into effect measures necessary to protect workers and others from risk as far as reasonably practicable.
3. Any vaccine-preventable disease that is transmissible from person to person poses a risk to both healthcare professionals and their patients. Health Care
Workers (HCW) have a duty of care towards their patients. This includes taking precautions, including vaccination, to protect then from communicable diseases.
4. Staff involved in direct patient care should be up to date with the following vaccinations: tetanus, diphtheria, polio, hepatitis B, Measles, Mumps and
Rubella (MMR), varicella and seasonal influenza. Separate Trust policies deal with hepatitis B immunisation and TB screening/BCG vaccination.
5. The MMR vaccine is especially important in the context of the ability of staff to transmit measles or rubella infections to vulnerable groups (e.g. the immunosupressed). Satisfactory evidence of protection includes documentation of having received 2 doses of MMR or having had positive antibody tests for measles and rubella.
6. Varicella (chickenpox) vaccine is recommended for susceptible HCW who have direct patient contact. Susceptible HCW can pose a significant health risk to high-risk patients and are themselves at risk of being infected by their patients. Chickenpox infection in adults can be extremely serious with a 10-
30% mortality rate. Those with a definite history of chickenpox or herpes zoster can be considered protected, although recent evidence showed that a history of chickenpox is a less reliable predictor of immunity in individuals born and raised overseas; therefore routine testing should be performed in this group.
7. Occupational Health will assess new employees during the Work Health
Assessment process for measles, mumps, rubella and varicella immunity.
Non-immune staff will be offered vaccination. New staff born after the introduction of MMR vaccine in 1988 who do not have evidence of 2 doses
MMR vaccine can proceed to vaccination without serological screening.
Written consent will be obtained before vaccination and a post vaccination information sheet provided.
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From the introduction of measles vaccination in 1968 until the late 1980s coverage was low and was insufficient to interrupt measles transmission.
Measles, Mumps and Rubella (MMR) vaccine was introduced in October 1988 and achieved coverage levels in excess of 90%. Because of the substantial reduction in measles transmission in the UK, children were no longer exposed to measles infection, and if they had not been immunised, they remained susceptible at an older age. In order to prevent a predicted epidemic, a UK vaccination campaign was started in November 1994 with measles-rubella (MR) vaccine. In 1996 a 2 dose MMR schedule was introduced.
All children should have received 2 doses MMR before leaving school. MMR can be given to individuals of any age and those who have not received MMR should be offered immunisation. With regard to vaccination in adults, individuals born between 1980 and 1990 may not be protected against mumps but are likely to be vaccinated against measles and rubella, although may have only had one dose of MMR. A second dose should be given in this case.
Those born between 1970 and 1979 may have been vaccinated against measles and many will have been exposed to mumps and rubella during childhood.
Those born before 1970 are likely to have had all three natural infections and are less likely to be susceptible. Serology should be checked in relevant staff groups and immunisation offered where indicated.
To inform the Trust’s employees about the risks and requirements pertaining to measles, mumps, rubella and Varicella in health care staff in the health care setting
The policy applies to all health care workers with direct patient contact
‘In the event of an infection outbreak, flu pandemic or major incident, the
Trust recognises that it may not be possible to adhere to all aspects of this document. In such circumstances, staff should take advice from their manager and all possible action must be taken to maintain ongoing patient and staff safety’
Measles
Measles is an acute viral illness transmitted via droplet infection. The incubation period is about 10 days (but may be up to 18 days). The signs and symptoms include runny nose, conjunctivitis, cough, Koplik spots (tiny white spots like grains of salt on the inside of the mouth), rash and fever. Complications include otitis media, pneumonia, convulsions and encephalitis. Measles infection in pregnancy can result in miscarriage or premature delivery.
Measles is highly infectious from up to four days before the rash appears to four days after the appearance of the rash. Until 1988 measles epidemics occurred every two or three years in the UK and therefore most UK adults are immune as a result of childhood infection or vaccination. Since 1988, exposure to natural measles has declined dramatically and younger members of the UK population who have not been fully vaccinated are likely to remain susceptible into adult life.
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An increasing proportion of the UK health care workforce is therefore at risk from measles infection. Between 1995 and 2000 a substantial number of cases of measles infection have been reported. Many of these have involved health care workers. Measles is highly infectious. Patients with immuno-suppressive disorders who are not immune to measles are at very high risk of acquiring infection from health care workers.
Mumps
Mumps is an acute viral illness caused by a paramyxovirus. It is usually characterised by parotid swelling and may be preceded by several days of nonspecific symptoms such as fever, malaise and headache. Asymptomatic infection is common in children. It is spread by airborne or droplet transmission with an incubation period of around 17 days. Neurological complications including meningitis and encephalitis can occur. Other complications include pancreatitis and orchitis. Before the introduction of MMR vaccine in 1988, mumps occurred commonly in school-age children and more than 85% adults had evidence of previous mumps infection. Initially high coverage of MMR vaccine resulted in a substantial reduction in mumps transmission in the UK, but since 1999 there has been an increase in confirmed mumps cases. In 2004 a further increase was seen with the majority of cases born between 1980 and
1987. Those most likely to lack immunity are adults born since 1980.
Rubella
Rubella is a mild infectious disease, most common among children aged 4 - 9 years. It causes a transient rash, swelling of glands at the back of the neck, and, occasionally in adults, mild pain and swelling in joints. Clinical diagnosis is unreliable since the symptoms can be caused by other viruses. A history of rubella should not be accepted without serological evidence of previous infection. The incubation period is 14-21 days and the period of infectivity is from one week before until four days after the onset of the rash. Maternal rubella infection in the first 8-10 weeks of pregnancy results in foetal damage in up to
90% of infants and multiple defects are common. The risk of damage declines to about 10-20% by 16 weeks and after this stage of pregnancy foetal damage is rare. Rubella is a notifiable disease. To avoid the risk of transmitting rubella to pregnant and non-immune patients, all Health Care Workers (HCW), both male and female, who have direct patient contact, should be screened for rubella antibodies by blood testing. Non-immune HCW should be immunised with MMR.
Varicella (chickenpox)
Varicella (chickenpox) is an acute, highly infectious disease caused by the
Varicella zoster (VZ) virus. It usually starts with one or two days of fever and malaise and then vesicles begin to appear on the face and scalp, spreading to the trunk, abdomen and finally limbs. After 3 or 4 days the vesicles dry with a granular scab and may be followed by further crops. The infectious period id from 1 or 2 days before the rash appears until the vesicles are dry. Herpes zoster (shingles) is caused by the reactivation of the patients Varicella virus.
Virus from lesions can be transmitted to susceptible individuals to cause chickenpox.
Varicella is transmitted directly by personal contact or droplet spread with an incubation period of one to three weeks. The infection is most common in children less than 10 years age, in whom it usually causes mild infection. The disease can be more serious in adults, particularly in pregnant women and in smokers, as they are at greater risk of fulminating Varicella pneumonia.
Pregnant women appear to be at greatest risk late in second or early in the third
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trimester. For neonates and immunosupressed individuals the risk of disseminated or haemorrhagic Varicella is greatly increased. Susceptible HCW can pose a significant health risk to high-risk patients. Susceptible HCW are at risk of being infected by their patients. Since chickenpox is so common in childhood, 90% of adults raised in the UK are immune.
Since 2003 it has been recommended that non-immune healthcare workers are vaccinated against Varicella. This gives protection to the HCW form infected patients but also protects non-immune patients.
Health Care Worker (HCW)

Clinical and other staff, including those in primary care, who have regular, clinical contact with patients. Includes doctors, dentists and nurses, paramedical professionals such as occupational therapists, physiotherapists, radiographers, ambulance workers and porters, and students in these disciplines

Laboratory and other staff (e.g. mortuary staff) who have direct contact with potentially infectious clinical specimens and may additionally be exposed to pathogens in the laboratory.

Non-clinical ancillary staff that may have social contact with patients, but not usually of a prolonged or close nature. This group includes receptionists, ward clerks and other administrative staff working in hospitals and primary care settings and maintenance staff such as engineers and cleaners.
Immunosupression

Current treatment with chemotherapy or generalised radiotherapy, or within 6 months of terminating such treatment

Organ transplant recipient and currently on immunosuppressive treatment

Bone marrow transplant recipients who are still considered to be immunosupressed, including those with graft versus host disease

Adults who have received a dose of around 40mg prednisolone per day for month than 1 week in the previous 3 months

Patients on lower doses of steroids, given in combination with cytotoxic drugs

Some individuals on lower doses of steroids or other immunosuppressant for prolonged periods, or who because of their underlying disease, may be immunosuppressed and at increased risk of infection.

Patients with evidence of impaired cell mediated immunity e.g. immunodeficiency syndromes
HIV positive: HIV positive individuals with or without symptoms should receive the following as appropriate: live vaccines (measles, mumps, rubella, polio) and inactivated vaccines (pertussis, diphtheria, tetanus, polio, typhoid, Hepatitis B,
Hib). HIV positive individuals should NOT receive BCG or yellow
Managers
All relevant managers in the health care setting should ensure that new and existing staff (including agency and locum staff and visiting HCW) are aware of the contents of this policy and that they have been cleared as fit for work following Occupational Health assessment.
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Occupational Health Department
Undertake screening and vaccination of employees as set out in process of this policy.
Employee
Comply with screening and vaccinations as set out in this policy and with other relevant Trust policies such as the Infection Control Policy
Measles, Mumps & Rubella
Occupational Health will undertake a Work Health Assessment for all new employees and screen existing staff on an opportunistic basis wherever possible. All HCW must have acceptable evidence of immunity to measles and rubella. Neither self reported disease nor a history of vaccination is considered adequate. Written documentation of vaccination with two doses of MMR vaccine or serological evidence of positive antibody tests for measles and rubella are required.
New staff born after the introduction of MMR vaccine in 1988 who do not have evidence of having received 2 doses of MMR vaccine will be offered vaccination without prior serological screening as set out in the Green Book (see references).
Written consent will be obtained before vaccination is given and a post vaccination information sheet provided.MMR vaccine provides protection for around 90% of recipients for measles and mumps and over 95% for rubella.
MMR contains live attenuated measles, mumps and rubella viruses. Since the vaccine viruses are not transmitted, there is no risk of infection from those recently vaccinated.
Susceptible (no evidence of immunity) HCW who refuse vaccination, should be advised on possible work restrictions and their duty of care towards colleagues and patients. It remains the managers decision to employ HCW or not when informed of such a refusal.
Staff case of, or contact with case of measles
If a staff member reports contact with a case of measles, or infection control inform OH about a possible case in a patient, attempts will be made to confirm the diagnosis in the case. If confirmation is not possible, but the diagnosis is still suspected, the situation will be managed as if it was measles. Staff members who are of unknown immune status should be blood tested for antibodies. Staff members who are antibody negative should be considered for prophylactic immunisation and managed as follows:
From the 7th day after contact to the 18th day after contact with the case, they must take their temperature every morning and not come to work if they are pyrexial (i.e. 37.2
ºC or higher), feel unwell, or have any sign of a rash. Provided they follow the above instructions, staff can continue to work during this period but they must not work with immunocompromised patients or pregnant women.
Temporary redeployment for these staff may need to be considered.
Varicella
The Occupational Health Department screen all new clinical employees during the Work Health Assessment process. Those with a definite history of chickenpox or herpes zoster can be considered protected. HCW with a negative or uncertain history of chickenpox or herpes zoster should be serologically tested and vaccine offered only to those without VZ antibody. A recent survey showed
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that a history of chickenpox is a less reliable predictor of immunity in individuals born and raised overseas (MacMahon et al ., 2004) and routine testing should be considered.
Vaccination will be offered to non-immune staff. Varicella vaccine is a live attenuated vaccine. Written consent will be obtained before vaccination and a post vaccination information sheet given to the employee. Pregnancy must be avoided between the doses and for 3 months following the second dose of vaccine. HCW will be told at the time of vaccination that they may experience a local rash around the site of the injection or a more generalised rash in the month after vaccination. In either case, they should report to the Occupational
Health Department for assessment before commencing work. If the rash is generalised and consistent with a vaccine-associated rash (papular or vesicular) the HCW should avoid patient contact until all the lesions have crusted. HCW with localised vaccine rashes that can be covered with a bandage and/or clothing should be allowed to continue working unless in contact with immunosupressed or pregnant patients. In the latter situation, an individual risk assessment should be made.
If a HCW is exposed to Varicella or herpes zoster between the 1st and 2nd dose of the vaccine, the second dose should be given immediately (after discussion with Virology Consultant).Post vaccination serological testing is not routinely recommended but is advisable for HCW in units dealing with highly vulnerable patients e.g. transplant units.
Management of HCW exposed to VZ virus infection
Vaccinated HCW or those with a definite history of chickenpox or zoster should be considered protected and be allowed to continue working. As there is a remote risk that they may develop chickenpox, they should be advised to report to OHD if they feel unwell and develop a rash or fever.
Unvaccinated HCW without a definite history of chickenpox or shingles and having a significant exposure to VZ virus should be excluded from contact with patients from eight to 21 days after exposure. There is some evidence that
Varicella vaccine administered within 3 days of exposure may be effective at preventing chickenpox (Varivax is licensed for post-exposure prophylaxis). OHD will liaise with Infection Control staff in these circumstances. In any case, vaccine should be offered to reduce the risk of the HCW exposing patients to VZ virus in the future.
HCW with localised herpes zoster on a part of the body that can be covered with a bandage and/or clothing should be allowed to continue working unless they are in contact with high risk patients, in which case an individual risk assessment should be carried out.
Information contained in this policy will be made available at general staff inductions, Junior Doctor Inductions, sharps training and health promotion activities and educational written material produced within the Trust
1. Immunisation against infectious disease 2006. ‘The Green Book’. UK
Department of Health
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Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds. This policy has been assessed accordingly.
Our values are the core of what Portsmouth Hospitals NHS Trust is and what we cherish. They are beliefs that manifest in the behaviours our employees display in the workplace. Our Values were developed after listening to our staff.
They bring the Trust closer to its vision to be the best hospital, providing the best care by the best people and ensure that our patients are at the centre of all we do. We are committed to promoting a culture founded on these values which form the ‘heart’ of our Trust:
Respect and dignity
Quality of care
Working together
No waste
This policy should be read and implemented with the Trust Values in mind at all times.
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10. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS
This document will be monitored to ensure it is effective and to assurance compliance.
Minimum requirement to be monitored
Lead Tool Frequency of Report of Compliance
Reporting arrangements Lead(s) for acting on
Recommendations
Audit of Occupational Health screening process- Work
Health Assessment of new
PHT employees
OH consultant physician audit annual Policy audit report to:

Health and Safety Committee
The effectiveness in practice of all procedural documents should be routinely monitored (audited) to ensure the document objectives are being achieved. The process for how the monitoring will be performed should be included in the procedural document, using the template above.
The details of the monitoring to be considered include:

The aspects of the procedural document to be monitored: identify standards or key performance indicators (KPIs);

The lead for ensuring the audit is undertaken

The tool to be used for monitoring e.g. spot checks, observation audit, data collection;

Frequency of the monitoring e.g. quarterly, annually;

The reporting arrangements i.e. the committee or group who will be responsible for receiving the results and taking action as required.
In most circumstances this will be the committee which ratified the document. The template for the policy audit report can be found on the Trust Intranet Trust Intranet -> Policies -> Policy Documentation

The lead(s) for acting on any recommendations necessary.
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